When a person has a cough and a fever, his or her doctor diagnoses pneumonia based on patient history, sounds in the chest, and interpretation of an X-ray. When a person is very sad, the doctor diagnoses depression based on five out of a possible nine symptoms listed under “Depression” in the “Diagnostic and Statistical Manual of Mental Disorders.”
Since 1952, the DSM, produced and periodically revised by the American Psychiatric Association, has been the “bible” of psychiatric diagnosis, studied by every medical student and referenced by every mental health clinician and researcher. The fact that the DSM is more subjective than most other diagnostic tools has seemed an inevitable consequence of the psyche’s complexity. But there have always been questions regarding its scientific validity and potential conflict of interest between the DSM’s authors and pharmaceutical companies. Gary Greenberg takes on the issue in “The Book of Woe: The DSM and the Unmaking of Psychiatry.” A practicing psychotherapist, Greenberg has made his concerns plain in incisive articles for Mother Jones, The New Yorker, and other periodicals. The titles of his two previous books — “The Noble Lie” and “Manufacturing Depression” — broadcast his skepticism.
Greenberg’s timing is right on: Last month, just weeks before the release of the newest edition, DSM 5, Dr. Thomas Insel, director of the National Institute of Mental Health, the nation’s leading funder of psychiatric research, wrote a blog post rejecting the logic of relying on the book. He called the DSM invalid, and an impediment to progress in understanding the biological basis of psychiatric illnesses. Insel wrote of the DSM: “Patients with mental disorders deserve better.”
In “The Book of Woe,” Greenberg takes the lay reader through a history of the DSM, which is really a history of psychiatry. He begins his fascinating and well-researched account in the late 19th century, when the founders of modern psychiatry disagreed about the nature of psychological suffering. Freud viewed such suffering in the context of personal and family histories, and resisted the notion of psychiatry as a branch of medicine. Kraeplin, a German psychiatrist and contemporary of Freud, thought of mental disorders as neatly classifiable medical entities.
More than a hundred years later, Greenberg argues, the DSM 5 has become irrelevant, in part, by failing to heed Freud. We simply don’t know enough about how the mind works to construct a reliable taxonomy of its infinite perturbations. The fact that, according to the DSM 5, Asperger’s syndrome is no longer characterized as a disease, while hoarding is, tells us less about those conditions than about the subjectivity involved in classifying them.
But worse than unreliable, Greenberg alleges repeatedly, the DSM 5 is dishonest. He details the less-than-transparent five-year, multimillion dollar process by which the DSM 5 was written, emphasizing the profits the APA stands to make by it. He is especially unsparing in profiles of psychiatrists he feels have used the DSM to push diagnoses that drive sales of certain drugs. Greenberg describes one Harvard doctor who favors the diagnosis of bipolar disorder in children as “on the take” of companies that make the antipsychotics now in widespread use to treat this condition.
In one of the surprisingly few patient examples Greenberg includes in “The Book of Woe,” he convinces us that “a child who seems unhappy nearly every waking moment . . . who holds a knife to his own throat and threatens to plunge it in if he isn’t allowed ten more minutes on PlayStation . . .” is liable to be misdiagnosed as bipolar, and overmedicated with drugs whose side effects include obesity and risk of suicide. But Greenberg skims a bit too quickly over the fact that this child and his family are in extreme pain.
The psychological pain that these people experience may be misnamed by the DSM but nevertheless it exists. Perhaps one day we will better understand why.
Suzanne Koven is a primary care internist at Massachusetts General Hospital and writes the monthly “In Practice” column for the Globe. She can be reached at firstname.lastname@example.org.